Administration of vorinostat disrupts HIV-1 latency in patients on antiretroviral therapy.

Despite antiretroviral therapy, proviral latency of human immunodeficiency virus type 1 (HIV-1) remains a principal obstacle to curing the infection. Inducing the expression of latent genomes within resting CD4(+) T cells is the primary strategy to clear this reservoir. Although histone deacetylase inhibitors such as suberoylanilide hydroxamic acid (also known as vorinostat, VOR) can disrupt HIV-1 latency in vitro, the utility of this approach has never been directly proven in a translational clinical study of HIV-infected patients. Here we isolated the circulating resting CD4(+) T cells of patients in whom viraemia was fully suppressed by antiretroviral therapy, and directly studied the effect of VOR on this latent reservoir. In each of eight patients, a single dose of VOR increased both biomarkers of cellular acetylation, and simultaneously induced an increase in HIV RNA expression in resting CD4(+) cells (mean increase, 4.8-fold). This demonstrates that a molecular mechanism known to enforce HIV latency can be therapeutically targeted in humans, provides proof-of-concept for histone deacetylase inhibitors as a therapeutic class, and defines a precise approach to test novel strategies to attack and eradicate latent HIV infection directly.

Do rainfed production systems have lower environmental impact over irrigated production systems?: On -farm mitigation strategies.

The intensive agriculture practices improved the crop productivity but escalated energy inputs (EI) and carbon foot print (CF) which contributes to global warming. Hence designing productive, profitable crop management practices under different production systems with low environmental impact (EI and CF) is the need of the hour. To identify the practices, quantification of baseline emissions and the major sources of emissions are required. Indian agriculture has diversified crops and production systems but there is dearth of information on both EI and CF of these production systems and crops. Hence the present study was an attempt to find hot spots and identify suitable strategies with high productivity, energy use efficiency (EUE) and carbon use efficiency (CUE). Energy and carbon balance of castor, cotton, chickpea, groundnut, maize, rice (both rainfed and irrigated), wheat, sugarcane (only irrigated), pigeon pea, soybean, sorghum, pearl millet (only rainfed) in different production systems was assessed. Field specific data on different crop management practices as well as grain and biomass yields were considered. Rainfed production systems had lower EI and CF than irrigated system. The nonrenewable sources of energy like fertilizer (64 %), irrigation (78 %), diesel fuel (75 %) and electricity (67 %) are the major source of energy input. Rainfed crops recorded higher CUE over irrigated condition. Adoption of technologies like efficient irrigation strategies (micro irrigation), enhancing fertilizer use efficiency (site specific nutrient management or slow release fertilizer), conservation agriculture (conservation or reduced tillage) rice cultivation methods (SRI or Direct seeded rice) were the mitigation strategies. These results will help policy makers and stake holders in adoption of suitable strategies for sustainable intensification.

Noise survey of neonatal intensive care unit at a government tertiary-care centre.

BACKGROUND: With technological advancement, Neonatal Intensive Care Units (NICU) have become noisier than ever. Studies have shown the detrimental effects of increasing noise in NICU on growing pre-term and sick neonates. The present study aimed to survey the amount of noise in one of the NICU blocks of a government tertiary care centre and explore ways to control it when dealing with these sick babies. METHODS: A detailed noise survey was carried out, for February 2023, in one of the two blocks of NICU in a government tertiary-care centre. The noise measurements were performed using two "Sound Ear 3" noise meters. The analyses were done in Leq (equivalent continuous sound levels) A-weighted decibels (dBA). RESULTS: The extracted data analysis revealed that the NICU block was exposed to a mean Leq of 67.78 dBA noise with a maximum of 89.0 dBA. There was a significant difference between the values noted in devices at different locations and across different periods. There were certain instances (57 and 42 for two devices) when there were sudden spikes in the noise levels beyond 80 dBA. It was also seen that noise was more than 65 dBA most of the time (72% and 66% for the two devices). CONCLUSION: The noise survey carried out over one month revealed a considerable amount of noise in the NICU of a government tertiary-care centre. The study also explored ways such as environmental modification, human behavior modification, awareness programs, and neonatal-centered modifications to reduce the noise and lower its detrimental effects on the growth of neonates.

Anaerobes in cardiac infections: A decade experience from the tertiary care center.

PURPOSE: Anaerobic infections are common yet life-threatening. They are being recovered from all sites of the body, including the cardiovascular system. This study was aimed to determine the retrospective analysis on the isolation of anaerobes in cardiovascular samples received for a decade-long duration. It helps in knowing the frequency of isolation of anaerobic causes of cardiovascular infection. METHODS: All cardiovascular samples from the department of Cardio-thoracic vascular surgery from January 2010 to December 2020 were studied. RESULTS: Of 601 samples received, predominant samples were vegetations and valvular tissues of 258, followed by 98 samples of pericardial tissues, 92 samples of embolus, 90 samples of blood and post-operative collections, and 63 excised aneurysms and vascular grafts. Of the total, 15 samples grew anaerobes where Clostridium species were the predominant isolates. Clostridioides difficile was isolated in 2 samples. CONCLUSIONS: Anaerobes in cardiovascular samples are uncommon yet form a significant cause of morbidity and mortality. Most infections are from the contiguous spread, penetrating trauma, and hematogenous causing endocarditis or valvular infections. These conditions and samples form the seat of infectious focus and clinical suspicion towards the anaerobic cause of these conditions, especially in conventional routine culture-negative samples. Timely diagnosis of anaerobic infections plays a vital role in the good prognostic outcome of patients undergoing cardiothoracic and vascular surgery.

Assessment of Genetic Polymorphisms in the Rewa Population of Central India Using Y-Chromosomal STR Markers.

The aim of the study was to analyze unrelated samples from the Rewa male population of Central India by targeting Y-short tandem repeats (STR) and then compare the results to previously published Y-STR haplotype data. Materials and Methods: A total of 181 unrelated male subjects from the Rewa population were genotyped for seventeen Y-STRs (DYS19, DYS389I, DYS389II, DYS390, DYS391, DYS392, DYS393, DYS385a/b, DYS437, DYS438, DYS439, DYS448, DYS456, DYS458, DYS635, and Y-GATA-H4) by using an AmpFlSTR® Yfiler™ multiplex kit (Thermo Fisher Scientific, USA). The allele frequencies and forensic parameters were evaluated. Results: A total of 111 distinct Y-STR alleles with corresponding frequencies ranging from 0.006 to 0.829 were identified. The gene diversity values ranged from 0.3092 at DYS437 to 0.8188 at DYS385b. The studied population showed a high level of haplotype diversity (0.9985) and discrimination capacity (0.927). A haplotype analysis was also conducted. Among the 181 unrelated male samples, 165 haplotypes and 153 unique haplotypes were found. Additionally, Rst (genetic distance) values were calculated using the analysis of molecular variance (AMOVA) for the studied population and for other 18 populations described in the literature. The Rst provides a convenient parameter for estimating the level of genetic differentiation from the microsatellite data. Based on these Rst values and using the multidimensional scaling plot, a neighbor-joining tree was constructed. Conclusion: The high values of haplotype diversity and discrimination capacity indicate a great potential for distinguishing between male individuals in the studied population. The present population data are expected to find their use in forensic caseworks and population genetics.

Myocardial performance index in term appropriate and small for gestational age neonates - a cross sectional study.

BACKGROUND: It is known that small for gestational age (SGA) babies may be at an increased risk of cardiovascular diseases during adulthood. There is paucity of literature regarding comparative cardiac functions of SGA and appropriate for gestational age (AGA) babies in neonatal period. The present study was conceived to compare the cardiac function of term small and appropriate for gestational age (AGA) babies through a relatively novel echocardiographic index in early neonatal period. OBJECTIVES: To compare values of myocardial performance index (MPI) index (MPI = IVCT + IVRT/ET) at 48-72 hours of age among AGA and SGA babies. METHODS: Morphological and anthropometric assessment of serially born term babies was done at time of birth to recruit hundred each of AGA and SGA babies. Tissue Doppler Imaging (TDI) was done between 48-72 hours for each enrolled baby to assess both right and left ventricle MPI in each group. RESULTS: Mean±SD values for right ventricular MPI in AGA and SGA groups were 0.268 + 0.007 and 0.30 + 0.026 respectively (p < 0.001). Mean±SD values for left ventricular MPI in AGA and SGA groups were 0.25 + 0.012 and 0.30 + 0.017 respectively (p < 0.001). There was significant negative correlation between MPI values for either ventricles and the birth weight (spearmen's rho of -0.66) (p < 0.001). Mean±SD values for LVET in AGA and SGA group were 0.304 + 0.026 and 0.266 + 0.032 respectively (p < 0.001). CONCLUSION: MPI had a higher absolute value in the SGA babies as compared to AGA babies. These observations point towards suboptimal cardiac performance among SGA babies as compared to AGA babies on the basis of myocardial performance index.

Inhibition of desmin expression blocks myoblast fusion and interferes with the myogenic regulators MyoD and myogenin.

The muscle-specific intermediate filament protein, desmin, is one of the earliest myogenic markers whose functional role during myogenic commitment and differentiation is unknown. Sequence comparison of the presently isolated and fully characterized mouse desmin cDNA clones revealed a single domain of polypeptide similarity between desmin and the basic and helix-loop-helix region of members of the myoD family myogenic regulators. This further substantiated the need to search for the function of desmin. Constructs designed to express anti-sense desmin RNA were used to obtain stably transfected C2C12 myoblast cell lines. Several lines were obtained where expression of the anti-sense desmin RNA inhibited the expression of desmin RNA and protein down to basal levels. As a consequence, the differentiation of these myoblasts was blocked; complete inhibition of myoblast fusion and myotube formation was observed. Rescue of the normal phenotype was achieved either by spontaneous revertants, or by overexpression of the desmin sense RNA in the defective cell lines. In several of the cell lines obtained, inhibition of desmin expression was followed by differential inhibition of the myogenic regulators myoD and/or myogenin, depending on the stage and extent of desmin inhibition in these cells. These data suggested that myogenesis is modulated by at least more than one pathway and desmin, which so far was believed to be merely an architectural protein, seems to play a key role in this process.

An epidemiological study of health and nutritional status of under five children in semi-urban community of Gujarat.

In developing countries, children of 0-5 years of age form a large as well as "high risk" group. Malnutrition poses a grave risk to the health of these children. The main objectives of this study were to assess the health & nutritional status of children of 0-5 years of age group & to study the influence of various epidemiological factors on health & nutritional status of children on 0-5 years of age group. It is a community based cross sectional study done in randomly selected three wards of Petlad town, district Anand in Gujarat state. 300 children of age group 0-5 years selected by systematic sampling method. Mother of each child included in the study was subjected to personal interview in her own house followed by clinical examination & anthropometric measurements of the child. The three indices of nutritional status namely, weight for age, height for age, & weight for height were expressed in standard deviation units from the median for the international reference populations as per WHONCHS standards & were compared with WHONCHS growth reference data. The prevalence of under weight (wt. for age below 2SD) was 43.67%. 50.3% children were found stunted (ht. 1br age below -2 SID) with higher prevalence in 2nd and 5th year of life. Prevalence of wasting (wt. for ht. below 2SD) was comparatively low (23.2% with a peak in 3rd year of life). These nutritional parameters showed a significant association with parental education, socio-economic status, family size, environmental conditions (safe drink water, sanitary waste disposal & overcrowding), & episodes of common diseases.

Anterior urethral valves.

Posterior urethral valves (PUV) are the most frequent cause of obstructive uropathy in boys. Rarer causes of obstructive uropathy include bladder diverticulae, meatal stenosis and urethral or bladder stones. Anterior urethral valves are rare causes of urinary obstruction in boys and are ten times less frequent than PUV in the literature(1-6). This paper highlights our experience with 5 patients with anterior urethral valves.

Management of bio-medical waste: awareness and practices in a district of Gujarat.

With the objective of assessing the level of awareness about the various aspects of biomedical waste and disposal practices by the medical practitioners this study was conducted. It was a cross sectional study. 30 hospitals with more than 30 beds minimum were randomly selected from Sabarkantha district, Gujarat. The doctors and auxiliary staff of those 30 hospitals were the study population. While all the doctors knew about the existence of the law related to biomedical waste but details were not known. Doctors were aware of risk of HIV and Hepatitis B and C, whereas auxiliary staff (ward boys, ayabens, sweepers) had very poor knowledge about it. There was no effective waste segregation, collection, transportation and disposal system at any hospital in the district. There is an immediate and urgent need to train and educate all doctors and the staff to adopt an effective waste management practices.

Induction of differentiation in murine erythroleukemia cells by 1 alpha,25-dihydroxy vitamin D3.

The Friend murine erythroleukemia (MEL) cells can be stimulated to differentiate in response to a variety of chemical inducing agents. In the present study, the effect of 1 alpha,25-dihydroxyvitamin D3 on differentiation of MEL cells was investigated. Vitamin D3 induced differentiation of MEL cells in culture as determined by elevated hemoglobin content, a rise in the number of benzidine-positive cells and increase in acetylcholine esterase activity. The optimum concentration of the vitamin required to induce differentiation of MEL cells was found to be 750 nM. The pattern of induction of differentiation was similar to that observed with DMSO and the induction of differentiation by vitamin D3 was inhibited by dexamethasone.

Fate of mild aortic valve disease after mitral valve intervention.

OBJECTIVE: This study was performed to assess the long-term outcome of untreated mild aortic valve disease present at the time of initial mitral valve intervention. METHODS: A total of 284 patients with rheumatic heart disease aged 7 to 62 years (mean, 23.5 +/- 12.2 years) who underwent mitral valve intervention and had mild aortic valve disease initially were followed up for 2 to 18 years (mean, 10.8 +/- 3.7 years). At initial intervention, 232 patients had pure mild aortic regurgitation, and 52 patients had mild aortic stenosis with or without aortic regurgitation. RESULTS: Among patients with mild aortic regurgitation initially, 11 (5%) patients progressed to moderate (n = 6) or severe (n = 5) regurgitation over an interval of 9 to 17 years (mean, 12.1 +/- 2.8 years), and 1 patient had moderate aortic stenosis and severe aortic regurgitation after 10 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic regurgitation was 100%, 97.0% +/- 1.7%, and 87.4% +/- 4.6% at 5, 10, and 15 years, respectively. Seventeen (35%) patients with initial mild aortic stenosis (with or without regurgitation) had moderate or severe stenosis (with or without moderate-severe regurgitation) after an interval of 4.9 +/- 3.8 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic stenosis was 75.6% +/- 6.2%, 61.5% +/- 8.5%, and 46.1% +/- 11.2% at 5, 10, and 15 years, respectively. Ten patients required aortic valve replacement for aortic valve dysfunction. CONCLUSIONS: Mild aortic regurgitation present at the time of mitral valve intervention progresses very slowly and less frequently requires reintervention. However, mild aortic stenosis diagnosed initially progresses more often and more rapidly and thus needs closer follow-up.

Pulmonary homograft: should it be used in the aortic position?

OBJECTIVE: Retrospective analysis was performed to determine the suitability of pulmonary homograft as an aortic valve substitute. METHODS: From January 1994 through June 1999, 147 patients (mean age, 32.2 +/- 17.3 years) underwent aortic valve replacement with either an aortic homograft (group 1: n = 103, 25 fresh antibiotic preserved and 78 cryopreserved) or a pulmonary homograft (group 2: n = 44, 11 antibiotic preserved and 33 cryopreserved). In group 1 a scalloped subcoronary technique was used in 64 patients, and a root replacement technique was used in 39 patients. In group 2 the scalloped subcoronary technique was used in 34 patients, and the root replacement technique was used in 10 patients. RESULTS: There were 131 operative survivors (group 1 = 91; group 2 = 40). Follow-up ranged from 2 to 62 months. In group 1 none of the patients had significant aortic regurgitation during the hospital stay. Three patients (all having undergone the scalloped subcoronary technique) had moderate aortic regurgitation after 6 to 32 months. In group 2, 10 patients (9 having undergone the scalloped subcoronary technique and 1 having undergone the root replacement technique) developed significant regurgitation: 2 intraoperatively, 5 in the early postoperative period before discharge from the hospital, and 3 during late follow-up 6 to 12 months postoperatively. Among the various risk factors analyzed for overall homograft failure, use of a pulmonary homograft was the single independent predictor of valve failure (odds ratio, 8.6; 95% confidence interval, 1.9-39; P =.006). CONCLUSION: Pulmonary homograft, when inserted by means of a scalloped subcoronary technique, is not a suitable aortic valve substitute.

Homograft mitral valve replacement: five years' results.

OBJECTIVE: Results of mitral valve replacement with a mitral homograft were evaluated at 5 years to assess the suitability of the procedure. METHODS: Thirty-seven patients (25 male subjects) aged 10 to 49 years (mean, 32 +/- 10 years) with rheumatic mitral valve disease underwent total (n = 35) or partial (n = 2) mitral valve replacement with a fresh antibiotic-preserved (n = 23) or cryopreserved (n = 14) mitral homograft. The predominant lesion was mitral stenosis (n = 30). RESULTS: There were 5 early deaths. Operative survivors were followed up for 1 to 60 months (mean, 26.6 +/- 12 months). Among these, 21 patients had severe mitral regurgitation during the follow-up period; 3 died and 8 underwent reoperation. The homograft failure rate was not affected by preoperative physiologic lesion (stenosis vs regurgitation, P =.4), type of homograft (antibiotic-preserved vs cryopreserved homograft, P =.9), papillary muscle pretreatment (yes vs no, P =.9), or addition of posterior collar annuloplasty (yes vs no, P =.2). Among the remaining patients, 5 had moderate mitral regurgitation, 4 had either trivial or mild mitral regurgitation, and 2 were lost to follow-up. Study of the explanted mitral homografts (n = 8) revealed that disruption of one of the donor papillary muscles was responsible for early failures (n = 2), whereas cuspal and chordal degeneration was responsible for late failures (n = 6). Microscopically, the explanted valve lacked any viable cellular elements, and there was no evidence of immunologic injury to the homografts. CONCLUSION: The mitral homograft did not fulfill our expectations as a suitable substitute for the diseased mitral valve.

Pulmonary autograft: should it be used in young patients with rheumatic disease?

BACKGROUND: Although pulmonary autograft is being increasingly used to replace the diseased aortic valve with excellent long-term results, its use in the population with rheumatic disease still needs careful evaluation. PATIENTS AND METHODS: From October 1993 through March 1998, 102 patients underwent aortic valve replacement with a pulmonary autograft (Ross procedure). The mean age was 27.9 +/- 4.2 years (range, 0.8-56 years). The cause was rheumatic disease in 75 patients (73%), bicuspid aortic valve in 26 patients (26%), and myxomatous aortoarteritis in 1 patient (1%). The root replacement technique was used in all. In addition, 31 patients had 33 associated procedures: mitral valve repair (n = 15 patients), open mitral commissurotomy (n = 15 patients), tricuspid repair (n = 2 patients), and homograft mitral valve replacement (n = 1 patient). RESULTS: Operative mortality was 6.9% (7 patients). Late mortality was 7.8% (8 patients). Follow-up ranged from 1 to 60 months (mean, 25.3 +/- 15.4 months) and was 98% complete. Two patients required reoperation for failed mitral valve repair, and 2 other patients underwent reoperation for failure of both the autograft and mitral valve repair. Echocardiographic assessment showed moderate to severe aortic regurgitation in 13 patients, along with thickening of the autograft. All of these patients had rheumatic disease and were young (<30 years). Ten of these patients had undergone associated mitral valve procedure. Morphologic and histopathologic examination of explanted autografts showed features compatible with rheumatic valvulitis. CONCLUSION: Pulmonary autograft is susceptible to rheumatic involvement. Young age (<30 years) and associated mitral valve disease are significant risk factors for autograft failure in patients with rheumatic disease. Use of pulmonary autograft in this subgroup of patients requires a cautious approach.

Tubercular pseudoaneurysms of aorta.

BACKGROUND: Tubercular pseudoaneurysm of aorta is a rare but important complication of tuberculosis. With worldwide resurgence of tuberculosis due to increasing incidence of drug-resistant tuberculosis and its association with acquired immunodeficiency syndrome, the tubercular pseudoaneurysm has become a real clinical entity. METHODS: In the past 3 years, 5 young patients (22 to 40 years) presented with tubercular pseudoaneurysm. Site of involvement included ascending aorta, distal aortic arch, proximal descending thoracic aorta, distal descending thoracic aorta, and infrarenal abdominal aorta. Two patients had macroscopic focus of tuberculosis in the nearby vicinity, and all 5 patients had evidence of active/treated pulmonary pericardial tuberculosis. All patients either had received antitubercular therapy previously or were receiving it at the time of presentation. Rapid deterioration in the clinical status was the most marked clinical feature. All patients underwent operation. Graft interposition was performed in 2, patch repair in 2, and direct closure of the rent was performed in 1 patient. All 5 patients received antitubercular therapy in the postoperative period. RESULTS: All patients survived the operation and were discharged from the hospital. One patient developed recurrence at the original site after 8 months and died at reoperation. The remaining patients are symptom free at 18 to 36 months postoperatively. CONCLUSIONS: A combination of chemotherapy and operation yields gratifying results for the treatment of tubercular pseudoaneurysm.

Surgical myocardial revascularization without cardiopulmonary bypass.

BACKGROUND: Though coronary artery bypass grafting (CABG) without cardiopulmonary bypass is being performed with increasing frequency, in the absence of adequate angiographic follow-up, safety, reproducibility, and efficacy of the procedure remain doubtful. In this prospective study, we report the results obtained by 100% angiographic follow-up of 96 consecutive patients. METHODS: A total of 96 patients (age range 33 to 76 years) underwent CABG without cardiopulmonary bypass. Single vessel disease was present in 46 (47.9%) patients, double vessel disease in 31 (32.3%), and triple vessel disease in 19 (19.8%) patients. All patients were operated through a standard midsternotomy and an optimal combination of pharmacological and mechanical methods were used to restrict cardiac movements during anastomosis. All patients underwent coronary angiography before discharge from the hospital. RESULTS: A total of 160 grafts were placed (range 1 to 4 grafts per patient, average 1.7+/-0.3 grafts per patient). A single graft was placed in 46 patients, double grafts in 38, triple grafts in 10, and quadruple grafts in 2 patients. Various grafts included pedicled left internal mammary artery (LIMA) (n = 95), free LIMA (n = 1), right internal mammary artery (n = 14), radial artery (n = 24), right gastroepiploic artery (n = 5), and saphenous vein grafts (n = 21). Operative mortality was 1.0% (1 of 96). Two patients required reoperation for excessive bleeding. Mean hospital stay was 5.7+/-1.2 days. Overall angiographic patency was 95.0% with LIMA patency of 97.9% (93 of 95). One patient with block in midsegment of LIMA was reoperated using cardiopulmonary bypass. Follow-up ranged from 4 to 17 months (mean 8.2+/-3.1 months). Two patients (one with narrowed LIMA to left anterior descending artery anastomosis, and one with patent anastomosis) had residual angina. CONCLUSIONS: Coronary artery bypass grafting without cardiopulmonary bypass is a reproducible, effective, and safe option in selected group of patients. A conscientious approach in patient selection and route of operation is required.

Right ventricular outflow tract after non-conduit repair of tetralogy of Fallot with coronary anomaly.

BACKGROUND: A total of 25 patients with tetralogy of Fallot and an important coronary artery crossing the right ventricular outflow tract underwent complete repair without use of an extracardiac conduit between January 1990 and December 1994. Repair was exclusively done by the transatrial or transatrial-transpulmonary approach. Age of these patients ranged from 1 to 12 years (mean 3.6 years). Three of the patients had already received a systemic to pulmonary artery shunt. METHODS: All patients reporting for follow-up (n = 18) were subjected to transthoracic echocardiography and, if required, cardiac catheterization and angiography. Right ventricle to pulmonary artery gradients were noted preoperatively, at discharge following repair and at follow-up study. RESULTS: Mean follow-up was 40.6 months (24 to 62 months). Mean early postoperative gradient was 23.5+/-13.4 mm Hg and 4 patients had significant (> 30 mm Hg) gradients. Mean late postoperative gradient was 20.6+/-12.4 mmHg and 2 patients had gradients greater than 30 mmHg. All the patients were in New York Heart Association functional class I at the time of last follow-up. CONCLUSIONS: Acceptable gradients across the right ventricular outflow tract are achievable following repair of tetralogy of Fallot in the presence of anomalous coronary artery across the right ventricular outflow tract using the transatrial or transatrial-transpulmonary approach. Most gradients were found not to vary significantly on subsequent follow-up.

Aneurysm of sinus of Valsalva dissecting into interventricular septum.

BACKGROUND: Dissection of interventricular septum by aneurysm of the sinus of Valsalva is extremely rare. We present our experience with the management of 10 patients with this condition. METHODS: Ten patients with aneurysm of the sinus of Valsalva dissecting into the interventricular septum were managed at All India Institute of Medical Sciences, New Delhi, between May 1987 and September 1996. Conduction abnormalities and aortic insufficiency dominated the clinical picture. Eight patients underwent surgical repair. Two patients refused operation, and only permanent pacemaker implantation was done for complete heart block in both these patients. RESULTS: There was no hospital mortality. Follow-up ranged from 1 to 9 years. There was one late death due to carcinoma of the larynx, and 1 patient required reoperation for persistent aortic insufficiency. All other patients who underwent operation are in New York Heart Association functional class I. CONCLUSIONS: We recommend surgical repair of this condition to deal with aortic regurgitation and to avoid the potential risk of rupture, thromboembolism, and infective endocarditis. However, surgical repair offers no guarantee against arrhythmias and conduction abnormalities.

Univentricular repair: is routine fenestration justified?

BACKGROUND: A decade after the introduction of baffle fenestration, the outcome of Fontan-type repair for hearts with a functional single ventricle finally looks promising. Our study was designed to assess the impact of fenestration on the outcome of univentricular repairs. METHODS: From January 1988 to December 1997, 348 patients (104 with tricuspid atresia and 244 with other morphological diagnoses) underwent univentricular repair at our institute. Since 1994, routine fenestration of the atrial baffle was performed in all patients (n = 126). RESULTS: The overall Fontan failure rate was 14% (50 of 348) and included 45 early deaths and five Fontan take downs. Absence of fenestration was the only and highly significant predictor of Fontan failure (risk ratio [RR] 3.3, 95% confidence interval [CI] 1.49 to 7.31, p = 0.002). Significant pleural effusion was seen in 27% of patients. Absence of fenestration of the atrial baffle (RR 3.97, 95% CI 2.17 to 7.26, p < 0.001) and aortic cross-clamp time more than 60 minutes (RR 2.15, 95% CI 1.3 to 3.5, p = 0.002) were found to be significant risk factors. The follow-up ranged from 6 to 120 months (mean 46.0 +/- 18.0 months). There were 12 late deaths and 5 patients were lost to follow-up. Actuarial survival (Kaplan Meier) at 90 months was 81% +/- 4%. Two hundred and fifty-eight patients (90%) were in New York Heart Association class I at their last follow-up visit. Oxygen saturation in the fenestrated group ranged from 85% to 94% (mean 89%). Thirty patients (26%) had spontaneous closure of the fenestration over a mean period of 34 months, and there has been no incidence of late systemic thromboembolism. In no instance has there been a need to close the fenestration. CONCLUSIONS: Elective fenestration of the intraatrial baffle is associated with decreased Fontan failure rate and decreased occurrence of significant postoperative pleural effusions. Routine elective fenestration of the atrial baffle may, therefore, be justified in all univentricular repairs.